Preventable medical errors threaten patient safety and are all
too common in hospitals throughout the world. These errors-the most severe of
which are called sentinel events, the less severe, adverse events-are not
limited to lower quality organisations; excellent healthcare organisations can
and do experience undesirable events. What separates excellent quality
organisations from lesser ones is whether they respond to sentinel and adverse events
in a way that significantly reduces the risk of the event occurring in the
future. By conducting intensive system analysis, revising processes found to
cause or contribute to these events, and monitoring the effectiveness of any
changes, quality hospitals create a safer patient environment following an
undesirable event.

With the release of the Joint Commission International
Accreditation Standards for Hospitals, 3rd edition, US-based accreditation body
Joint Commission International (JCI) introduced the international healthcare
community to the term sentinel event, which when combined with the already
familiar terms adverse event and near miss, describe the full range of
undesirable events with varying degrees of serious outcomes. JCI also began
requiring that all JCI-accredited hospitals heed JCI's Sentinel Event Policy
(see Figure 1) as a baseline for compliance and develop a sentinel event policy
of their own, as well as establishing a process to address a sentinel event
when it occurs.

JCI defines a sentinel event as an unanticipated death or loss
of function unrelated to the natural course of the patient's illness or
underlying condition or wrong-site, wrong-procedure, wrong-patient surgery.
Such an event is called sentinel because it signals a need for an immediate
investigation and response. An adverse event is defined by JCI as an
unanticipated, undesirable, or potentially dangerous occurrence in a healthcare
organisation, and a near miss is any process variation that did not affect an
outcome but for which a recurrence carries a significant chance of a serious adverse
outcome; such a “near miss” falls within the scope of the definition of an
adverse event.

Adhering to a sentinel event policy should not only reduce the
occurrence of sentinel events, but should also help healthcare organisations
create a culture committed to identifying errors before they occur as well as
being comfortable reporting errors if and when they happen. A blame-free
culture, recognising that sentinel and adverse events are often the result of
total system failure rather than individual practitioners' failures, should be
the basis of every sentinel event policy.

A blame-free culture is especially important in the intensive
care unit (ICU). Because ICU work is intense, with many interactions occurring
between patient and caregiver and as the nature of critical illness reduces both
patients' natural resilience and their ability to defend themselves from the
consequences of human error, patients in the ICU may be at a higher risk of
experiencing a sentinel or adverse event. According to one study, 54.8% of patients
who had been in an ICU during their stay had a serious adverse event as opposed
to only 38.1% of those who never been in an ICU (The Joint Commission Guide to
Priority Focus Areas, 2004). Researchers from the Harvard Medical Practice
study also concluded that patients 65- years-old or older had twice the risk of
experiencing an event due to negligence than did those between 16 and 45
(Brennan et al. 1991).

Although each event is unique, healthcare errors often have
common root causes that can be prevented from happening in the future when all organisations
are made aware of them. But, awareness
of the most common sentinel events and root causes of them is only made
possible when hospitals confidentially share their information with an
organisation such as JCI. In the United States, voluntary sentinel event
reporting has allowed the Joint Commission to create a database identifying
risk factors and trends, and this information is available to healthcare
organisations and others on the Joint Commission's website at http://www.jointcommission.org/SentinelEvents/
Statistics/. Although JCI does not currently maintain such a database (it plans
to establish such a resource in the near future) the US-based resource provides
applicable data, trends, and guidance for organisations everywhere.

Conclusion

Because sentinel events have such a dramatic and devastating
effect on patients, their families and also on the organisation and its staff,
policies and procedures are necessary at such time of calamity. But ultimately,
sentinel events are not about poli cies but all about people and learning and
the resolve to not let such an event occur again. Ask any family of a patient
who died from a sentinel event and they will relate that their one hope is that
no other family will have to go through the same event.

Hospitals are learning environments that incorporate new
knowledge and the latest scientific advances every day. The information and
findings resulting from the root cause of a sentinel event needs to be elevated
into that learning environment and the processes for improvement. To lock away
the findings out of shame or fear of loss of prestige is a disservice to those
affected by the event and leaves the same system vulnerabilities in place for
another day and another event - eventually. Organisations also need to learn
from the events that occurred in other organisations. This is facilitated by the
JCI International Center for Patient Safety where organisations can access the
best science and aggregate learning of the larger healthcare community. Patient
safety solutions are available for immediate review and action by organisations
ready to learn and incorporate new knowledge. This is a neverending cycle
necessary for quality and safe patient care today and tomorrow.

Sentinel Events

In support of its mission to improve the safety and quality of
healthcare provided to the international community, JCI reviews organisation
activities in response to sentinel events in its accreditation process. The following
apply:

• A sentinel event is an unanticipated occurrence involving
death or major permanent loss of function unrelated to the natural course of
the patient's illness or underlying condition.

• A sentinel event may occur due to wrong-site, wrong-procedure,
wrong patient surgery.

• Such events are called “sentinel” because they signal a need
for immediate investigation and response.

• The terms “sentinel event” and “medical error” are not
synonymous; not all sentinel events occur because of an error and not all errors
result in sentinel events. Goals of the
Sentinel Event Policy

The policy has four goals:

1. To have a positive impact in improving patient care,
treatment, and services and preventing sentinel events.

2. To focus the attention of an organisation that has
experienced a sentinel event on understanding the causes that underlie the event,
and on changing the organisation's systems and processes to reduce the
probability of such an event in the future.

3. To increase general knowledge about sentinel events, their
causes, and strategies for prevention.

4. To maintain the confidence of the public and internationally
accredited organisations in the accreditation process.

Expectations for an Organisation's Response to a Sentinel Event

Accredited organisations are expected to identify and respond
appropriately to all sentinel events occurring in the organisation or associated
with services that the organisation provides, or provides for. Appropriate response
includes conducting a timely, thorough, and credible root cause analysis; developing
an action plan designed to implement improvements to reduce risk; implementing the
improvements; and monitoring the effectiveness of those improvements. Reasons for Reporting a Sentinel Eventto JCI Although self-reporting a sentinel event is not
required and there is no difference in the expected response, time frames, or
review procedures, whether the hospital voluntarily reports the event or JCI
becomes aware of the event by some other means, there are two major advantages
to the hospital that self-reports a sentinel event:

• Early reporting provides an opportunity for consultation with
JCI central office staff during the development of the root cause analysis and
action plan.

• The organisation's message to the public that it is doing
everything possible to ensure that such an event will not happen again is
strengthened by its acknowledgement and collaboration with JCI to understand
how the event happened and what can be done to reduce the risk of such an event
in the future.

No comment

Highlighted Products

Features
The SynoVent E3 does not only include advanced ventilator functionality but also a modern, easy to use interface. The display can be configured to suit each clinician’s taste and needs, and gives quick and easy control over ventilator parameters...

The HAMILTON-C1 neo is a versatile neonatal ventilator that combines invasive and noninvasive modes with the additional options of nCPAP and high flow oxygen therapy. The integrated turbine allows it to be operated independently of a compressed air supply....

Medos hemofilters pro are used for efficient and gentle hemofiltration during extracorporal circulation.Medos hemofilters pro do not need to be pre-flushed and can be used immediately. This guarantees a safe and quick hemofiltration.

The HAMILTON-C3 ventilator is a modular high-end ventilation solution for all patient groups. Offering a number of unique features, the HAMILTON-C3 is one of the first ventilators featuring the “Ventilation Autopilot” INTELLiVENT-ASV®. The HAMILTON-C3’s...

NovaPort cannulas: The safe access to the vascular system. NovaPort® twin double lumen cannulas are specifically developed for veno-venous vascular access. NovaPort one single lumen cannulas are specifically developed for the percutaneous connection (KU)...